Periodontal pocket

Oral Periodontology Department

1. By: Lobna el saadawy Periodontal Pocket

2. OUTLINE - Definition. -Classification - Clinical features & histopathology -Pocket composition -Pathogenesis -Pocket as a healing lesion -Periodontal pocket detection -Management

3. Definition Periodontal pocket is defined as pathologic deepening of the gingival sulcus

4. CLASSIFICATION 1)Gingival pocket 2)Periodontal pocket Classified according to : The relation to the crestal bone b) The number of surfaces involved

5. Gingival pocket (pseudo pocket ) : gingival enlargement without destruction of the underlying periodontal tissues Periodontal pocket: This type of pocket occurs with destruction of the supporting periodontal tissues

6. 1. According to the relation to the crestal bone Suprabony supracrestal / supraalveolar Intrabony subcrestal / intraalveolar

7. Suprabony pocket 1.Base of pocket is coronal to the level of alveolar bone. 2.Horizontal pattern of bone destruction. 3. pdl fibers beneath pocket follow their normal Horizontal- oblique course. 4.Transeptal fibers are arranged horizontally. Infrabony pocket 1.Base of pocket is apical to crest of alveolar bone , intrabony pockets most often occur interproximally but may be located on the facial or the lingual tooth surfaces. 2.Vertical (angular) pattern of bone destruction. 3.Pdl fibers follow angular pattern. 4. Transeptal fibers are arranged obliquely.

8. 2. According to the number of surfaces involved Simple : Pocket involving one tooth surface Compound : Pockets involving more than one tooth surface Complex : (spiral ) originating on one tooth surface and twisting around the tooth to involve one or more additional surfaces This type of pockets is most common in furcation areas

9. Clinical features & histopathology

10. Symptoms Localized Pain and sometimes radiating deep into bone. Sensitivity to hot and cold Food impaction Foul taste in localized areas

11. CLINICAL FEATURES 1. Various degrees of bluish red discoloration. -Flaccidity. -Smooth shiny surface. -Pitting on pressure. 2.Gingival wall may be pink and firm. 3.Bleeding on probing. 4.On probing inner aspect of wall is generally painful. 5.Pus may be expressed on applying digital pressure. HISTOPATHOLOGIC FEATURES 1.Circulatory stagnation. -Destruction of gingival fibers. -Atrophy of epithelium. -Edema 2.Fibrotic changes . 3.Increased vascularity, thinning and degeneration of epithelium. 4.Ulceration of inner aspect of pocket wall. 5.Suppuratiove inflammation of inner wall.

12. Pocket Composition Soft tissue wall Hard tissue wall pocket content

13. First : pocket content Microorganisms and their products (enzymes, endotoxins, and other metabolic products), Gingival fluid Food remnants Salivary mucin Desquamated epithelial cells, and leukocytes. Plaque-covered calculus usually projects from the tooth surface Purulent exudate

14. Significance of Pus formation Pus is a common feature of periodontal disease, but it is only a SECONDARY SIGN It is NOT AN INDICATION OF THE DEPTH of the pocket or the severity of the destruction of the supporting tissues

15. Second: soft tissue wall Inflammatory changes in the connective tissue wall : = Destructio n of collagen fibers just apical to the  junction epithelium , as this area becomes occupied by inflammatory cells and edema =As a consequence of the loss of collagen, the apical cells of the junctional epithelium proliferate along the root, extending fingerlike projection two or three cells in thickness = PMNLs invade the corona l end of the junctional epithelium When the volume of PMNLs reach 60% of the junctional epithelium, the tissues looses cohesiveness and detach from the tooth structure

16. Collagen loss is caused by 2 mecahnisms PMNLs and macrophages secrete collagenase and other lysosymes extracelluaraly and destroy collagen fibers in gingival CT ( matrix metalloproteinases ) Fibroblast phagocytize fibers by extending cytoplasmic process to the ligament cementum interface and degrade the collagen fibers in the cementum matrix

17. Collagen loss is followed by Degeneration of the junctional epithelium and pocket formation  The coronal portion of the junctional epithelium detaches from the root as the apical portions migrates The apical cells of the junctional epithelium proliferate along the root extending fingerlike projections

18. Migration of the junctional epithelium requires healthy, viable cells Therefore, marked degeneration or necrosis of the junctional epithelium retards rather than accelerates pocket formation

19. Third : Root surface wall Collagen fibers embedded in the cementum ( Sharpey’s Fibers) are destroyed Cementum becomes exposed to the oral cavity Bacterial penetration in to cementum leads to breakdown of the cementum surface and necrotic cementum results that will be separated from tooth by masses of bacteria .

20. In the course of treatment, these necrotic areas are removed by root planing until a hard smooth surface is reached. Cementum is very thin in the cervical areas, and scaling and root planing often removes it entirely , exposing the underlying dentin . Sensitivity to cold may result until secondary dentin is formed by the pulp tissue

21. Chemical Changes in Cementum Areas of hyper mineralization Due to deposited minerals from salvia on cementum surface (calcium, phosphorus, magnesium and fluoride Decrease the sensitivity, making its resistant to dental caries

22. Areas of demineralization Exposure to oral fluid and bacterial plaque results in proteolysis of the embedded remnants of Sharpey's fibers The cementum may be softened and may undergo fragmentation and cavitation Leads to increase sensitivity, caries, & pulpitis may occur

23. Surface Morphology of Pocket Walls Five zones can be seen the base of the pocket Cementum covered by calculus. Attached plaque Zone of unattached plaque. Zone where the junction epithelium is attached to the tooth. The zone of semi destroyed C.T. fibers. (3, 4, 5 called plaque free zone)

24. Pathogenesis

25. - The initial lesion in the development of periodontitis is the inflammation of the gingiva in response to a bacterial challenge . - Changes involved in the transition from the normal gingival sulcus to the pathologic periodontal pocket are associated with different proportions of bacterial cells in dental plaque . - Healthy gingiva is associated with few microorganisms , mostly coccoid cells and straight rods. While Diseased gingiva is associated with increased numbers of spirochetes and motile rods

26. Early concepts : assumed that after the initial bacterial attack, periodontal tissue destruction continued to be linked to bacterial action . More recently : it was established that the host’s immunoinflammatory response to the initial and persistent bacterial attack unleashes mechanisms that lead to collagen and bone destruction.

27. Genetics and Interventional studies implicating complement C3 as a major target for the treatment of periodontitis J Immunol . 2014 Jun 15;192(12):6020-7. doi : 10.4049/jimmunol.1400569. Epub 2014 May 7 .

28. Chronic periodontitis leads to inflammatory destruction of tooth-supporting tissues C3 complement is a point of convergence of complement activation mechanisms , but its involvement in periodontitis was not previously addressed .

29. We investigated this question using two animal species models, namely, * C3-deficient or wild-type mice with the local application of C3 complement In mice, C3 was required for maximal periodontal inflammation and bone loss . * nonhuman primates (NHPs ) locally treated with a potent C3 inhibitor. local treatment of NHPs with C3 inhibitor inhibited ligature-induced periodontal inflammation and bone loss, together with lower gingival crevicular fluid levels of proinflammatory mediators (e.g., IL-17 and RANKL) as compared with control treatment.

30. C onclusion This is the first time to prove that: complement inhibition inhibit inflammatory processes that lead to bone loss . These data strongly support the feasibility of C3-targeted intervention for the treatment of human periodontitis.

31. Overexpression and Potential Regulatory Role of IL-17F in Pathogenesis of Chronic Periodontitis . Inflammation 2014 Nov 11. Epub 2014 Nov 11 Zhenhua Luo , Hui Wang, Jiajun Chen, Jian Kang, Zheng Sun, Yafei Wu

32. 1) Periodontal local tissues were obtained from chronic periodontitis (CP) and healthy controls (HC) for real-time PCR (RT-PCR) detection with IL-17F and IL-17A messenger RNA (mRNA ). 2) Primary human gingival fibroblasts (HGF) were derived from patients receiving crown-lengthening procedures. E levated levels of IL-17F and IL-17A mRNA in CP gingival tissues compared with HC group . There is a correlation between IL-17F and IL-17A mRNA in CP group with the probing depth RESULTS

33. 3 ) IL-17F and IL-17A were used to stimulate the HGF cells . 4) Production of pro-inflammatory cytokines induced by IL-17F and IL-17A was detected by RT-PCR . Both IL-17F and IL-17A could promote the inflammatory cytokines IL-6, CXCL8, and CCL20 production This study indicates that IL-17F may be involved in pathogenesis of periodontitis like IL-17A. The role of IL-17F in disease pathogenesis needs to be further investigated RESULTS

34. Periodontal disease activity

35. Periodontal pockets go through periods of exacerbation and quiescence Periods o f quiescence Reduced inflammatory response little or no loss of bone and connective tissue attachment Period o f exacerbation Bone and connective tissue attachment are lost and the pocket deepens Bleeding, either spontaneously or with probing Greater amounts of gingival exudate

36. Pocket as a Healing lesion

37. Periodontal pockets constantly undergoing repair. Complete healing does not occur because of the persistence of the local irritants.

38. The condition of the soft tissue wall of the periodontal pocket result from the destructive & constructive tissue changes . The balance between the destructive & constructive changes determines the clinical features ; (color ,consistency ,surface texture of the pocket wall.)

39. Thus pocket wall can be either Soft & friable pocket wall Fibrotic pocket wall

40. Attachment loss versus Probing depth

41. Probing depth: It ‘s the distance between the point of resistance under light pressure at the base of the pocket and the crest of the gingival margin Attachment loss: It ‘s the distance between the point of resistance under light pressure at the base of the pocket and the cementoenamel junction

42. Severity of bone loss is generally, but not always, correlated with pocket depth Extensive attachment loss & bone loss may be accompanied with shallow pockets in case of gingival recession And slight bone loss can occur with deep pockets

43. Pocket Probing The two different pocket depths are: Biologic or histologic depth Clinical or probing depth

44. Biological Depth - Vs -Clinical Depth The distance between the gingival margin and the base of the pocket c an be measured only in carefully prepared histologic sections . The distance to which the probe penetrates into the pocket clinically clinical depth Histological depth

45. Detection of pockets

46. The only accurate method of detecting and measuring periodontal pockets is careful exploration with a periodontal probe

47. Limitations of radiograph The periodontal pocket is a soft tissue change . Radiographs indicate areas of bone loss where pockets may be suspected They do not show pocket presence or depth, and consequently they show no difference before or after pocket elimination unless bone has been modified.

48. Gutta Percha points or Calibrated Silver points can be used with radiograph to assist in determining the level of attachment of periodontal pocket.

49. Clinic or Probing Depth The distance to which the probe penetrates into the pocket. The depth of penetration of a probe in a pocket depends on: Size of the probe Force with which it is introduced Direction of penetration Resistance of the tissues Convexity of the crown

50. Probing technique The probe should be inserted parallel to the vertical axis of the tooth and walked circumferentially around each tooth to detect the area of deepest penetration

51. To detect interproximal crater Probe should be placed obliquely from both facial and ligual surfaces so as to explore the deepest point of the pocket located beneath the contact point.

52. In multirooted teeth The possibility of furcation involvement should be carefully explored with Nabers probe

53. P eriodontal P ockets Management

54. Management of periodontal pockets include I) Non surgical management ; Including : a) phase I therapy b) local drug delivery c) systemic antimicrobials II) Surgical management ; including : a) resective surgeries - gingival currettage - gingivectomy - flap operation b) regenerative surgeries.

55. Randomized Controlled Trial Assessing Efficacy and Safety of Glycine Powder Air Polishing in Moderate-to-Deep Periodontal Pockets This study assesses efficacy and safety of subgingivally applied glycine powder air polishing ( SubGPAP ) in moderate-to-deep periodontal pockets Thomas F. Flemmig ,* Daniyel Arushanov ,* Diane Daubert ,* Marilynn Rothen ,† Gregory Mueller ,†and Brian G. Leroux Submitted June 21, 2011 .

56. Subgingival debridement was performed in deep periodontal pockets by SubGPAP using a thin nozzle inserted into the periodontal pocket (A ) in shallow periodontal sites by SupraGPAP using a conventional hand piece aimed directly into the periodontal pocket (B ). Supragingival biofilm and stain were removed in all sites by SupraGPAP directed perpendicular to the tooth surface (C).

57. SubGPAP resulted in significantly lower total viable bacterial counts ( as it is more efficacious in removing subgingival biofilm) in moderate-to-deep pockets when compared to SRP . full-mouth GPAP may result in a beneficial shift of the oral microbiota and appears to be well tolerated There were no adverse events related to full-mouth GPAP. Results :

58. Effect of tetracycline HCl in the treatment of chronic periodontitis - A clinical study . Sinha S1, Kumar S2, Dagli N3, Dagli RJ4 . J Int Soc Prev Community Dent. 2014 Sep;4(3)

59. This study was aimed to evaluate the efficacy of the adjunctive use of tetracycline fibers (Periodontal Plus AB(®)) as a local drug delivery with scaling and root planing , as compared with the results of one episode of scaling and root planing for the treatment of chronic periodontitis.

60. RESULTS: Significant improvement was found in all the variables, including reduction in p.d and gain in C.A.L, in both test and control groups in 3 months But Mean reduction in P.D and gain in C.A.L were more in test than in control group. CONCLUSION : Tetracycline fiber therapy along with scaling and root planing improves the healing outcome, namely, reduction in pocket depth and gain in clinical attachment level, when compared to scaling and root planing alone .

61. In the treatment of periodontal infections The local application of antibiotics in periodontal pockets may be a promising approach to achieve sustained/controlled drug release , high antimicrobial activity and low systemic side effects . the effectiveness of conventional nonsurgical treatment is limited by lack of accessibility to bacteria in deeper periodontal pockets. Development of local drug delivery systems provides an answer.

62. Novel local drug delivery agents used for the treatment of periodontal diseases are alendronate and simvastatin delivered as gels. Alendronate is a novel bisphosphonate is a very potent inhibitor of bone resorption . The net effect of alendronate on bone formation might be explained by its inhibition of osteoclasts , thus affecting bone maturation and remodeling. Alendronate

63. Once taken up by bone, alendronate has a prolonged skeletal retention (half-life up to several years ) Alendronate gel has been found to increase bone formation on local delivery into the periodontal pocket . In patients with type 2 diabetes mellitus and chronic periodontitis, local delivery of 1% alendronate gel into periodontal pockets resulted in: a significant increase in the probing depth ( p.d ) reduction , clinical attachment level (A.L)gain , and improved bone fill compared to placebo gel as an adjunct to scaling and root planning . Pradeep AR, Sharma A, Rao NS, BajajP , Naik SB, Kumari M. Local drug delivery of alendronate gel for the treatment of patients with chronic periodontitis J Periodontol . 2012 .

64. Simvastatin (SMV) is a specific competitive inhibitor of 3-hydroxy-2-methyl-glutaryl coenzyme -A reductase . Pardeep et al [35] showed : a greater decrease in gingival index and probing depth and a clinical attachment level gain at sites treated with scaling and root planing plus locally delivered SMV gel in patients with chronic periodontitis. Pradeep AR, Thorat MS. Clinical effect of subgingivally delivered simvastatin in the treatment of patients with chronic periodontitis: a randomized clinical trial. JPeriodontol . 2010 Simvastatin

65. Impact of Local and Systemic Alendronate on Simvastatin-Induced New Bone Around Periodontal Defects Amy C. Killeen,* Pota A. Rakes,* Marian J. Schmid ,† Yijia Zhang,‡ Nagamani Narayana ,† David B. Marx,§ Jeffrey B. Payne,* Dong Wang,‡ and Richard A. Reinhardt * December 2012

66. Simvastatin has been shown to stimulate new bone growth on rat mandibles, but much of the bone is lost over time The purpose of this study: is to evaluate the impactof a systemically applied anti resorptive agent (alendronate ) on simvastatin-induced bone formation Conclusion: The use of a short course of systemic ALN during the healing period after bone anabolic SIM injections has the potential to enhance local bone augmentation.

67. Boric acid irrigation as an adjunct to mechanical periodontal therapy in patients with chronic periodontitis: a randomized clinical trial Sağlam M1, Arslan U, Buket Bozkurt Ş, Hakki SSJ Periodontol . 2013 Sep;84(9):1297-308. doi : 10.1902/jop.2012.120467. Epub 2012 Nov 3 .

68. The purpose of this clinical trial was to evaluate the effects of boric acid irrigation as an adjunct to SRP on clinical and microbiologic parameters and compare this method with chlorhexidine irrigation and SRP alone in patients with chronic periodontitis (CP ) boric acid could be an alternative to chlorhexidine , and it might be more favorable because boric acid was superior in whole-mouth BOP as well as PD and CAL reduction for moderate pockets . Conclusion

69. Photo disinfection of Periodontal Pockets Written by Véronique Benhamou , BSc, DDS March 2009

70. Photodisinfection of Periodontal Pockets Methylene blue dye is gently injected into the periodontal pocket The dye binds to the Peptidoglycan layer on the cell walls of both gram-negative and gram-positive bacteria

71. Because of a difference in thickness of the peptidoglycan layer in their cell walls , GRAM-NEGATIVE Bacteria take up the methylene blue stain FASTER .

72. Meanwhile, the Periowave nonthermal diode laser produces photons whose frequency matches that of the molecule of the methylene blue dye. When the photons hit the dye molecules, they initiate the photodynamic chain of events. The oxygen molecules surrounding the dye are caused to lose an electron, and thus become free radicals . The free oxygen radicals are toxic to the bacterial cell walls and disrupt them, leading to the destruction of the bacteria .

73. Photodisinfection treatment is not meant to replace traditional mechanical SRP therapy but rather to complement i t . Photodisinfection may also be used during periodontal surgery to “disinfect” areas that may be difficult to instrument (such as furcations ), particularly prior to regenerative procedures

74. Gingival Pocket (pseudopocket) Management Treatment of pockets includes: PHASE 1 THERAPY then surgical removal of gingiva is done ( Gingivectomy )

75. Periodontal Pocket Management I) Suprabony Pocket Phase 1Therapy Maintenance F lap surgery

76. Flap Surgery

77. Infrabony Pocket

78. The use of a membrane: 1) maintaining space for clot stabilization . 2 ) Is for the prevention of epithelial migration along the cemental wall of the pocket thus temporarily separating them from the gingival epithelium and connective tissue Excluding the epithelium and the gingival connective tissue from the root surface during the postsurgical healing phase not only prevents epithelial migration into the wound but also favors repopulation of the area by cells from the periodontal ligament and the bone RESULTING IN :

79. Bone graft materials are evaluated based on their osteogenic , osteoinductive , or osteoconductive potential . Osteogenesis refers to the formation of new bone by cells contained in the graft. Osteoinduction is a chemical process by which molecules contained in the graft (e.g., bone morphogenetic proteins ) convert the neighboring cells into osteoblasts, which in turn form bone. Osteoconduction is a physical effect by which the matrix of the graft forms a scaffold that favors outside cells to penetratethe graft and form new bone

80. Clinical Effectiveness of Diode Laser Therapy as an Adjunct to Non-Surgical Periodontal Treatment: A Randomized Clinical Study - August 2013 The use of 980 nm diode laser in adjunct to scalling and root planning in comparison to scaling and root planning only

81. Laser therapy showed improvement only in probing dept h in moderate pockets ( 4-6 mm) while no difference in Bleeding on probing nor Clinical attachment loss For patients with aggressive periodontitis the adjunct use of diode laser with scaling and root planing ( SRP) has shown superior effect over SRP alone CONCLUSION

82. Studies that used 980 nm diode laser demonstrated that non surgical application of diode laser modulate and induce mRNA expression of growth factors in gingival fibroblasts . Limited results of laser therapy in this study may be due to the reduction of the laser power at the finer optic tip so finer optic tips need to be cleaved to minimise reduction in laser power output during curettage

83. Morphological Alterations of Periodontal Pocket Epithelium Following Nd:YAG Laser Irradiation Ting Chun-Chan, Fukuda Mitsuo , Watanabe Tomohisa , Sanaoka Atsushi, Mitani Akio, and Noguchi Toshihide . Photomedicine and Laser Surgery. November 13, 2014

84. Conclusion The scanning electron microscopy and histologic findings demonstrated the feasibility & effectivity of ablating pocket epithelium with an Nd:YAG laser irradiation

85. Effects of citric acid and EDTA conditioning on exposed root dentin: An immunohistochemical analysis of collagen and proteoglycans Alessandra Ruggeri Jr.a , Carlo Pratib , Annalisa Mazzonia , Cesare Nuccib , Roberto Di Lenardac , Giovanni Mazzottia , Lorenzo Breschic jan 2007

86. Conclusions This study supports the hypothesis that: manual or ultrasonic instrumentation alone is not able to expose the sound dentin matrix, whereas a subsequent acidic conditioning exposes collagen fibrils and associated proteoglycans . The immunohistochemical technique revealed that despite their acidity , both citric acid and EDTA were able to preserve the structural and biochemical properties of the exposed dentin matrix